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The Practice of Medicine

Talk Doesn’t Pay

As explored in a post last week, the practice of medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but new the transition can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry, as noted in this New York Times article.

The Times article highlights the practice of Dr. Donald Levin of Doyletown, Pennsylvania.  Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.

“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.” The switch from talk therapy to medications has swept psychiatric practices and hospitals.

Points to ponder and background for the transition:

  • Specifically, a 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since.
  • Insurance company reimbursement rates and policies frequently discourage talk therapy.
  • A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.
  • Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so frequently begin their practice with less education-related debt — is a reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

And the effect on the patients?

  • Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago.

And are 15-minute sessions adequate for evaluating how well medications are working?  “I’m good at it,” Dr. Levin noted, “but there’s not a lot to master in medications. It’s like 2001: A Space Odyssey, where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.” Read more…

Say Farewell to the Family Doctor?

Remember the solo family doctor? In in some places, as noted in this Wall Street Journal/Smart Money article, it has become increasingly likely that she’s collecting a paycheck from a large regional hospital—and practicing medicine according to the hospital’s strict playbook.

Nationwide at least one in six doctors—more than 150,000—now works as an employee of a hospital system. And with about half of recent medical school graduates deciding to work for hospitals and many established doctors looking to unload their practices amid the tough economic climate, what was a trickle of change has turned into a torrent. Jim Pizzo, a Chicago-area hospital consultant, says the blistering pace of these mergers is leading some colleagues to joke that there are two types of physicians today: “Those employed by hospitals and those about to be.”

Is this trend (if there is enough evidence to suggest a real trend) problematic, or at the very least what are its upsides and downsides for patients?

Whether they wear suits or scrubs, many physicians think they’re doing the right thing. Hospital executives say they’re adapting to the rapid evolution of the health care business, while physicians, worn thin running businesses during the recession, are drawn to the safety of a salary and regular hours as well as the appeal of not having to deal with many other administrative issues small business owners have to work through, such as the hassles of office space and tenancy, benefits packages, and of course the question of access to costly medical equipment.

What’s less clear is how the fever to buy up local doctors’ offices will affect the paper-gowned patients caught in the middle, with many saying they’ve already seen costs rise or treatment choices dwindle. Consumer advocates say the demise of the neighborhood doctor could turn out to be as big a change for medicine as anything happening at the national level with health care reform. “The story of how well these collaborations will actually work, day after day, hasn’t been written yet,” says Roland Goertz, president of the American Academy of Family Physicians. Read more…

The Rigors of Treating the Patient in Chief

No patient gets closer medical attention than the president of the United States. Wherever he goes, a doctor, nurse or paramedic trails a few footsteps behind, ready for any medical need. It is the ultimate in concierge medicine.

For the president’s doctor, it is a little different, as detailed in this New York Times article. The job of White House physician combines professional responsibility with the glamour and trappings of proximity to history. The White House medical office is only a few steps from the Oval Office, and the doctor has automatic access to the president’s living quarters.

A medical staff member stays overnight in the White House. When the president travels, the doctor rides in a limousine near the head of the motorcade. Jet lag and stress make the job one of near-constant fatigue, shadowed by dread of assassination attempts.

Now a recent holder of the job, Dr. Connie Mariano, has written an account of her nine-year tenure under three presidents, Bill Clinton and both George Bushes. The book, The White House Doctor: My Patients Were Presidents — a Memoir, is one of just a handful of autobiographical accounts by presidential physicians.

Dr. Mariano’s story is an inspiring one. The daughter of a Navy steward, she was the first Filipino-American of either sex to rise to rear admiral, and the first woman in the military to become the White House physician. Read more…

Spine Surgery, Medical Advances, and an Aging Population

A condition known as spinal stenosis is one of the top reasons older Americans seek surgery for lower back pain, and the number of people afflicted with the disorder is expected to grow as the population ages. A recent study in the Journal of the American Medical Association (JAMA), as detailed in this Wall Street Journal article, looked at the situation.

Some orthopedic doctors are concerned the procedure has gotten more complicated than it needs to be as some surgeons combine traditional stenosis therapy with other procedures that fuse vertebrae. The more complex surgery can be beneficial for some patients, especially those with more than one spinal disorder. But it also raises the cost of treatment and increases the chances of complications, including stroke and death, recent research shows:

  • The number of complex spinal surgeries has grown at a rapid rate:, now accounting for 19.9 per 100,000 surgeries from 1.3 per 100,000.
  • Although patients suffering only stenosis and not other spinal conditions were less likely to receive the combined procedures, these patients still accounted for as many as 50% of the complex surgeries.
  • The higher rate of complex procedures increased hospital costs for surgery by 40%.
  • The complication rate of those cases also was higher at 5.6% compared to 2.3% for the simpler, decompression surgery.
  • Hospitals stays were on average two days longer for complex surgery.
  • Average per-patient hospital charges were $80,888, compared with $23,724 for the simpler surgery.

Why the rate of increase? An aging population is inherently going to mean an increase in the number of spine surgeries in general, as vertebra naturally degenerate over time. However, the rate of increase currently happening is far greater than that transition would call for.

“Many factors are at play, but I think the finances play an important part,” says Richard Deyo, a professor of evidence-based medicine at Oregon Health & Science University in Portland, Ore., and lead author of the JAMA study. “There are some prominent surgeons who have strong financial connections to device manufacturers.”

Christopher Bono, an orthopedic surgeon at Brigham and Women’s Hospital in Boston, says the JAMA article doesn’t explain why the surgery numbers are increasing other than “insinuating that it is because of marketing and surgeon greed.” He says there could be other reasons for the increase “such as better corrections of deformities.”

“It has not been shown that the more complex surgery is better [for patients with simple stenosis], but people are willing to have it done,” says Eugene J. Caragee, an orthopedic surgeon at Stanford University School of Medicine, who has written on the topic in medical journals. “The marketing is relentless,” he says. Read more…

Why Parents Fear the Needle

Last month MCNtalk raised the question of paranoia around the issue of vaccinations in Vaccinations and Autism: Junk Science Isn’t a Victimless Crime. As a follow-up to this issue—with its very serious public health implications—MCNtalk is exploring the issue further.

This article in the New York Times looks at why the public would be so receptive and responsive to the results of one very limited study, noting “[it’s] because the public’s underlying fear of vaccines goes much deeper than a single paper. Until officials realize that, and learn how to counter such deep-seated concerns, the paranoia — and the public-health risk it poses — will remain.” Read more…

Sex, Lies and Videotape – and the Internet


We hesitated a bit before posting this. It is not often that we can see a combination in one event that includes the perils of the Internet, workers’ compensation, dishonesty, and perhaps human greed combined with ignorance.

We find these cases interesting on a social level. Typically the amount of money misappropriated in cases like this of probable malingering is in the tens or hundreds of thousands; an amount that would result in criminal charges if a person walked into their employer or someones else’s house and stole it. But in the case of clear and convincing evidence that an individual is faking injury or extent of injury, denial of subsequent benefits or as in this case, payback of prior payments seems more common. What is the difference between this situation and theft and why is prosecution not the norm?

While the majority of claims are valid and respond to appropriate treatment and rehabilitation, cases of fraud and malingering when they occur are costly and troublesome, and underscore at times larger social issues. This case also underscores the value of searching for information about claimants that are not under their direct control in the medical context. Historically this involved surveillance, but as this case demonstrates, the Internet – typically social networking sites, often provides a wealth of intentional or unintentional self-disclosure.

Discovering the new normal: It’s not just “small talk” when it comes to assessing life quality

Per this New York Times article, when physicians fail to ask probing questions about quality of life, addressing only the physical aspects of a chronic illness, they are likely to miss serious problems that can be remedied — among them depression, sleep disruption, loss of sexual desire and difficulty with everyday or pleasurable activities.

Of course, everyone knows that a doctor’s time these days is limited. But for medical care to be delivered efficiently and economically, assessing health-related quality of life is an essential element that can help doctors identify therapy that is counterproductive or ineffective or needs to be modified.

As Dr. Gordon H. Guyatt of McMaster University in Hamilton, Ontario, put it in an article in the Mayo Clinic Proceedings,  “If the primary goal of therapy is to improve the way patients feel,” assessing quality of life when making clinical decisions is essential. And it is the patient, not the physician, who obviously defines “quality of life” for themselves.

Identifying a disease’s effects on patients’ quality of life can result in treatments and self-management techniques that may enable them to reclaim their former lives. Arthritis patients, for example, might try to be more physically active and better control their weight. Or, as Dr. Rainer, author of Arthritis Self-Management put it, “Quality of life depends on how well you can integrate new circumstances into your life.”

 

Vaccinations and Autism: Junk Science Isn’t a Victimless Crime

In 1998, a British surgeon named Andrew Wakefield published a paper claiming that the measles-mumps-rubella (MMR) vaccine might cause autism. To support his case, Dr. Wakefield reported the stories of eight children who had developed symptoms of autism within one month of receiving MMR.

As several different investigations—summed up in a British Medical Journal (BMJ) editorial this month—have shown, not a single aspect of Dr. Wakefield’s notion of how MMR causes autism has proven correct. And 14 studies have been conducted since 1998 on several continents and involving thousands of children—and none of these studies found any link whatsoever between the vaccine and autism.

In the meantime, how was the initial report received? To put it simply, many nervous parents—many of whom could also have been aware of at least anecdotal evidence of a rise in autism— didn’t have their children vaccinated, or postponed vaccinations until after their children were already exposed to, and exposing their peers to, very serious health risks. And the results are disastrous to the children and the rest of the population. The State of California is experiencing the largest whooping cough epidemic in over half a century. After thousands of parents in the United Kingdom and Ireland chose not to vaccinate their children against MMR, hundreds of children were hospitalized and four killed by measles. In 2008, for the first time in 14 years, measles was declared endemic in England and Wales.

How did one paper have such a drastic effect? This Wall Street Journal article explores the situation—the MMR/autism link is an extraordinary claim backed by scant evidence— and several more systemic failures, including the push for publication of an article after it had been rejected by multiple journals; repeated media references to the article even though it involved only eight children; and some questionable behavior on Dr. Wakefield’s part in receiving received tens of thousands of pounds from a personal-injury lawyer in the midst of suing pharmaceutical companies over MMR. Read more…

Paying peanuts for health care after 500 billion percent inflation?

Yes, the IMF estimates that prior to 2008 Zimbabwe’s rate of inflation reached 500 billion percent.

Since then, a power-sharing government has formed after years of decline under President Robert Mugabe, and the economy has stabilized. Zimbabwe abandoned its currency last year, replacing it with the American dollar, and inflation has fallen to a demure 3.6 percent. Teachers are back in their classrooms and nurses are back on their wards.

But a recent United Nations report suggests how far Zimbabwe has to go. It is still poorer than any of the 183 countries the United Nations has income data for. It is also one of only three countries in the world to be worse off now on combined measures of health, education and income than it was 40 years ago, the United Nations found. And in the past 25 years, life expectancy has dropped by 14 years on average: a child born in Zimbabwe today can expect to live to the age of 47, nearly 40 years shorter than the longest lifespans enjoyed on the planet today.

In the wake of such a disastrous state of affairs, this New York Times article explores how Zimbabweans are paying for their medical care – through the barter system.

Low-Cost Dental Care Reflects Wider National Debate

There’s a debate shaping up in Alaska regarding whether dental therapists should be allowed to perform procedures such as administering fillings and completing extractions. Alaska is currently the only state which allows for dental therapists to perform invasive procedures; ten other states are considering legislation to expand (or recognize) the role of dental therapists in a similar manner per this New York Times article.

The debate highlights multiple hot topics in health care discussion today:

  • Access to healthcare (The therapists, who receive two years of training, help fill a vacuum: Alaska has long had trouble attracting and retaining licensed dentists. Given Alaska’s huge size and rural population, for many state residents a trip to the dentists – or any health care practitioner – can be a lengthy event.).
  • The ethnic and socioeconomic divide in health care: 60 percent of Alaska Native children ages 2 to 5 have untreated decay, and 20 percent of Native adults over 55 have no teeth at all.
  • Which professions have the legal right to treat patients in what manner.  
  • Long-term care/preventive care medicine vs. short-term care. (When discussing the ramifications of a dental therapist performing an extraction, Dr. Raymond Gist, the American Dental Association president, notes that: “If you have a person suffering from pain, that person has advanced disease,” said  “I would want that person to see a licensed dentist without delay.” Would an extraction necessarily prevent disease from spreading, or will the patient end up needing yet another extraction as disease spread?)

No one is arguing that patients shouldn’t receive care. But how this particular discussion plays out is an important reflection of a much wider national discussion.